A dermatopathologist is a specialist in diagnosing skin biopsies under the
microscope. Both pathologists and dermatologists may apply for certification.
Dermatologists must complete additional surgical pathology training while
pathologists must complete clinical dermatology training. Upon completion,
eligible candidates may take the board examinations given by both the American
Boards of Dermatology and Pathology. Board certification in Dermatopathology
qualifies the physician specialist as a designated expert in the diagnosis
of skin diseases. They work closely with pathologists and dermatologists providing
consultative expertise in difficult skin lesions and biopsies. Because of
their unique knowledge base, dermatopathologists often moderate conferences
such as Dermatology Grand Rounds where patients with unusual skin diseases
are presented in a conference setting along with the skin biopsy. The clinical
findings are correlated with the biopsy findings. Dermatopathologists can
also play an important role with compliance issues for office based dermatology
laboratories.

Calgary Laboratory Services and Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada.

Arch Pathol Lab Med. 2003 Nov;127(11):1489-92. Abstract quote

CONTEXT: Slide review has been advocated as a means to reduce diagnostic error in surgical pathology and is considered an important component of a total quality assurance program. Blinded review is an unbiased method of error detection, and this approach may be used to determine the diagnostic discrepancy rates in surgical pathology.

OBJECTIVE: To determine the diagnostic discrepancy rate for skin biopsies reported by general pathologists.

DESIGN: Five hundred eighty-nine biopsies from 500 consecutive cases submitted by primary care physicians and reported by general pathologists were examined by rapid-screen, blinded review by 2 dermatopathologists, and the original diagnosis was compared with the review interpretation.

RESULTS: Agreement was observed in 551 (93.5%) of 589 biopsies. Blinded review of these skin biopsies by experienced dermatopathologists had a sensitivity of 100% (all lesions originally reported were detected during review). False-negative errors were the most common discrepancy, but false positives, threshold discrepancies, and differences in type or grade were also observed. Only 1.4% of biopsies had discrepancies that were of potential clinical importance. C

CONCLUSIONS: Blinded review demonstrates that general pathologists reporting skin biopsies submitted by primary care physicians have a low diagnostic error rate. The method detects both false-negative and false-positive cases and identifies problematic areas that may be targeted in continuing education activities. Blinded review is a useful component of a dermatopathology quality improvement program.

Is histological examination of tissue removed by general practitioners
always necessary? Before and after comparison of detection rates of
serious skin lesions.

Lowy A, Willis D, Abrams K.

Department of Epidemiology and Public Health, University of Leicester,
Faculty of Medicine.

BMJ 1997 Aug 16;315(7105):406-8 Abstract quote

OBJECTIVES: To examine whether histological examination of all tissue
removed by general practitioners in minor surgery increases the rate
of detection of clinically important skin lesions, and to assess the
impact of such a policy on pathologists' workload.

DESIGN: Before and after comparison.

SETTING: Stratified random sample of 257 general practitioner partnerships
from the catchment areas of 19 English pathology laboratories.

SUBJECTS: Tissue removed in minor surgery by general practitioners
during the control period (September 1992 to February 1993) and intervention
period (September 1993 to February 1994).

INTERVENTION: General practitioners referred to their local pathology
laboratory all solid tissue removed in all minor surgery, irrespective
of their previous policy.

MAIN OUTCOME MEASURES: Numbers of specimens referred for histology
by general practitioners during intervention and control periods; numbers
of primary malignant melanomas, non-melanoma malignancies, premalignant
lesions, and benign lesions.

RESULTS: 257/330 partnerships participated (response rate 78%). During
the intervention period 5723 specimens were sent, compared with 4430
during the control period. The referral rate increased by an estimated
1.34 specimens per 1000 patient years (95% confidence interval 0.93
to 1.76, P < 0.0001). General practitioners sent 204 specimens that
were malignant (including 16 malignant melanomas) in the control period
and 188 that were malignant (including 15 malignant melanomas) during
the intervention period (change in total number of malignancies, -1.0
per 100,000 patient years (-5.9 to 3.8, non-significant).

CONCLUSIONS: The intervention was associated with a substantial increase
in laboratory workload, all of which was accounted for by increases
in non-serious lesions. This observation should be taken into account
when considering the merits of a policy requiring histological examination
in every case.

VARIANTS

UNSTAINED SLIDES

Unstained negative image patterns. A checkpoint for quality slides.

Head ES, Tschen EH.

Am J Dermatopathol 1982 Apr;4(2):143-8 Abstract quote

Before stains were available, pathologists had to rely on unstained
sections viewed through crude microscopes, but they still were able
to make diagnoses and discoveries. Unstained sections may still be used
to advantage in making diagnoses of skin lesions quickly, accurately,
and easily on the basis of negative image patterns.

Low-power scanning by conventional microscopy of freshly cute and mounted,
still wet, paraffin sections of skin specimens enables the histotechnologist
and dermatopathologist to accomplish three things: 1) to check orientation
of the sections at an early stage, 2) to cut complete sections, and
3) to find the area or areas of pathology to cut. Furthermore, because
diagnoses can be made from unstained sections, extra cuts for special
stains may be ordered in advance of routine staining.

The dermato-pathology laboratory is able, therefore, to produce slides
of better quality and diagnoses more accurately and quickly.

BACKGROUND AND DESIGN: Managed care organizations may direct dermatopathologic
specimens to anonymous consultants. I hypothesized that the quality
of the consultation decreases when there is no incentive for an anonymous
consultant to actively pursue the dermatologist/consumer. Therefore,
I examined 364 consecutive specimens that had been directed to anonymous
consultants. The specimens were obtained from patients who consulted
a university-based dermatology clinic or the office of a collaborating
practitioner. The quality of consultation was evaluated in 5 areas:
factual correctness, arguable differences in degree, evidence that the
history had been read by the consultant, knowledge of dermatologic disease
evident in the interpretative aspects of the report, and appropriate
direct interaction with the referring physician when indicated.

RESULTS: There was concordance between the interpretation by anonymous
consultants and the findings of my review in 66.8% of cases that involved
common dermatopathologic diagnoses. There were errors in fact in 26
cases (7.1%). There were examples of failure to correlate histologic
findings with clinical history, apparent lack of understanding of dermatologic
disease, and failure to resolve conflicts between the histologic pattern
and the clinical information.

CONCLUSIONS: I found a decrease in the quality of biopsy specimen interpretation
received from anonymous consultants. Dermatologists need to maintain
and/or upgrade their skills in dermatopathology to supervise the quality
of interpretation obtained from anonymous consultants.

TURN-AROUND-TIME

Log-in/log-out time: a quality factor for a reference laboratory--prolonged
times for skin pathology processing in managed care-authorized laboratories.

Managed care organizations may divert skin biopsy specimens to commercial
laboratories selected on a cost basis. Diversion to these laboratories
could result in service of decreased quality for the patient and referring
physician. Log-in/log-out dates were collected for all specimens submitted
to managed care-authorized laboratories either from a university-based
clinic or from a private practitioner's office for a period of 18 months
and compared with data obtained from a local dermatopathology laboratory.
A subgroup of specimens containing inflammatory diagnoses or nondiagnostic
changes was also examined.

Mean log-in/log-out times were 1.338 days in the dermatopathology laboratory,
6.123 days in managed care-authorized laboratories from the university
site, and 7.798 days in managed care-authorized laboratories from a
practitioner's office. The differences between the dermatopathology
laboratory log-in/log-out times and those of the managed care-authorized
laboratories were statistically significant (p < 0.0001).

The conclusion from this study is that a quality indicator defined
as time from log in to log out revealed a significant increase in interpretation
time at managed care-designated laboratories. Although managed care
plans can decrease their financial risk by contracting with national
laboratories to provide all services for a set fee, a decreased quality
of service can be demonstrated.